Management of Stage 3a CKD (GFR 65 mL/min/1.73 m²)
A patient with GFR 65 mL/min/1.73 m² has Stage 3a chronic kidney disease and requires initiation of CKD-specific monitoring and interventions to slow progression and prevent complications, though nephrology referral is not yet indicated at this level of kidney function. 1
Immediate Diagnostic Assessment
Confirm CKD diagnosis by documenting persistent kidney dysfunction:
- Repeat GFR measurement after 3 months to confirm chronicity, as CKD requires abnormalities present for >3 months 2, 3
- Measure urine albumin-to-creatinine ratio (ACR) to complete risk stratification using the CGA classification (Cause, GFR category, Albuminuria category) 1, 2
- Obtain urinalysis to assess for hematuria, proteinuria, or active sediment 1
- Review medication list to identify and eliminate potential nephrotoxins, particularly NSAIDs 1, 3
Blood Pressure Management
Target blood pressure <130/80 mmHg for all patients with CKD: 1
- Initiate ACE inhibitor or ARB if albuminuria is present (ACR ≥30 mg/g), as these agents slow CKD progression in patients with albuminuria 1
- Do not discontinue ACE inhibitor/ARB for creatinine increases <30% from baseline in the absence of volume depletion 1, 4
- Monitor serum potassium after initiating renin-angiotensin-aldosterone system (RAAS) blockers 1
Monitoring Schedule for Stage 3a CKD
Establish regular monitoring every 6-12 months: 1
- Measure eGFR and urine albumin every 6-12 months to assess progression rate 1, 5
- Check serum electrolytes (sodium, potassium, bicarbonate) every 6-12 months 1
- Screen for complications that emerge when GFR falls below 60 mL/min/1.73 m²: 1
Cardiovascular Risk Reduction
Aggressively manage cardiovascular risk factors, as cardiovascular disease is the leading cause of death in CKD: 3
- Initiate statin therapy for cardiovascular risk reduction 3, 5
- Optimize glycemic control if diabetic (target A1C ≤7%) to slow progression 1, 5
- Consider SGLT2 inhibitor if diabetic, as these provide kidney protection even at this GFR level 1
Dietary Modifications
Implement kidney-protective dietary changes: 1
- Limit dietary protein to 0.8 g/kg/day (the recommended daily allowance); avoid higher protein intake >1.3 g/kg/day which accelerates progression 1
- Restrict sodium intake to <2,300 mg/day to control blood pressure 1
- Individualize potassium intake based on serum potassium levels 1
Medication Safety
Adjust medication dosing based on GFR and avoid nephrotoxins: 1, 3
- Review and adjust doses of renally cleared medications (many antibiotics, oral hypoglycemics, anticoagulants) 3, 5
- Avoid NSAIDs and minimize exposure to iodinated contrast 1
- Verify appropriate dosing for all medications at this GFR level 1
Nephrology Referral Criteria
Nephrology referral is NOT indicated at GFR 65 mL/min/1.73 m² unless specific high-risk features are present: 1, 4
- Refer if rapid progression occurs (eGFR decline >5 mL/min/1.73 m² per year) 4, 3
- Refer if heavy proteinuria develops (>1 g/day or ACR ≥60 mg/mmol) 4
- Refer if GFR drops to <30 mL/min/1.73 m² 1, 4
- Refer if refractory hypertension (requiring ≥4 antihypertensive agents) develops 4
- Refer if uncertain etiology of kidney disease or active urinary sediment 4
Common Pitfalls to Avoid
- Do not rely on serum creatinine alone—always calculate eGFR using validated equations (CKD-EPI preferred) that account for age, sex, and race 2, 3
- Do not diagnose CKD based on a single GFR measurement—persistence for >3 months is required 2, 3
- Do not use ACE inhibitors/ARBs without albuminuria solely for CKD prevention—these are indicated for hypertension treatment or when albuminuria is present 1
- Do not delay establishing the diagnosis—delayed recognition of CKD is associated with worse outcomes, including increased risk of progression to kidney failure and cardiovascular events 6